Perineal Repair Research Articles

Midterm complications after primary obstetrical anal sphincter injury repair in France

BackgroundIncidence of complications following obstetrical anal sphincter injury (OASI) during vaginal delivery are poorly defined. They are only studied in high level maternities, small cohorts, all stages of perineal tear or in low-income countries. The aim of our study was to describe complications after primary OASI repair following a vaginal delivery in all French maternity wards at short and midterm and to assess factors associated with complication occurrence.MethodsWe conducted a historical cohort study using the French nationwide claim database (PMSI) from January 2013 to December 2021. All women who sustained an OASI repair following a vaginal delivery were included and virtually followed-up for 2 years. Then, we searched for OASIS complications. Finally, we evaluated factors associated with OASIS complication repaired or not and OASIS complication repairs.ResultsAmong the 61,833 included women, 2015 (2.8%) had an OASI complication and 842 (1.16%) underwent an OASI complication repair. Women were mainly primiparous (71.6%) and 44.3% underwent an instrumental delivery. During a follow-up of 2 years, 0.6% (n = 463), 0.3% (n = 240), 0.2% (n = 176), 0.1% (n = 84), 0.06% (n = 43) and 0.01% (n = 5) of patients underwent second surgery for a perineal repair, a fistula repair, a sphincteroplasty, a perineal infection, a colostomy and a sacral nervous anal stimulation, respectively. Only one case of artificial anal sphincter was noticed. Instrumental deliveries (OR = 1.56 CI95%[1.29;1.9]), private for-profit hospitals (OR = 1.42 [1.11;1.82], reference group “public hospital”), obesity (OR = 1.36 [1;1.84]), stage IV OASIS (OR = 2.98 [2.4;3.72]), perineal wound breakdown (OR = 2.8 [1.4;5.48]), ages between 25 and 29 years old (OR = 1.59 [1.17;2.18], refence group “age between 13 and 24 years old”) and 30 and 34 years old (OR = 1.57 [1.14; 2.16], refence group “age between 13 and 24 years old”) were factors associated with OASIS complication repairs.ConclusionsMaternal age, stage IV OASIS, obesity, instrumental deliveries and private for-profit hospitals seemed to predict OASIS complications. Understanding factors associated with OASIS complications could be beneficial for the patient to inform them and to influence the patient’s follow-up in order to prevent complications, repairs and maternal distress.

Less is more: Outcomes of surgical approaches to rectal prolapse in patients with cirrhosis

BackgroundPatients with cirrhosis have increased risk of perioperative complications, and surgical management of concomitant rectal prolapse poses a challenge in these patients. Given the paucity of data informing this, our study aimed to evaluate postoperative outcomes. MethodsThe National Surgical Quality Improvement Program database was queried for patients undergoing rectal prolapse repair from 2011 to 2019. Patients were stratified by cirrhosis (Model for End-Stage Liver Disease ≥10) and no cirrhosis. Bivariate and multivariable regression analyses were used to compare comorbidities, repair types, and identify predictors of postoperative outcomes. ResultsWe identified 2,234 patients: 332 patients with cirrhosis (Model for End-Stage Liver Disease 14 [10–34]). Patients with cirrhosis were older (76 ± 12 years vs 69 ± 17, P < .001) with increased comorbidities (eg, heart failure, lung disease), greater mortality (3.6% vs 0.8%, P < .001), and complication rates compared with patients without cirrhosis. Readmission rates and longer hospital stays also were observed in patients with cirrhosis. A total of 52% of NCPs underwent abdominal repair compared with 62% of patients with cirrhosis who received perineal repair; greater complication rates were observed for abdominal repairs in both groups (patients without cirrhosis 11.4%, patients with cirrhosis 25%). Predictors of greater complication rates in patients with cirrhosis included abdominal repair (odds ratio 2.7, 95% confidence interval 1.4–5, P = .002) and presence of ascites (odds ratio 4.6, 95% confidence interval 1.1–20, P = .04). ConclusionOverall, abdominal repairs have greater complication rates even when controlling for Model for End-Stage Liver Disease score and presence of ascites. The Delorme procedure had the lowest complication rates. Additional evidence is needed to recommend a preferred surgical approach to rectal prolapse repair in patients with cirrhosis.

Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain.

Different clinical practice guidelines include recommendations on how to prevent and repair obstetric perineal trauma, as well as the use of episiotomy. To evaluate the variability in midwives' professional practices for preventing and repairing perineal trauma, as well as the professional factors that may be associated with the restrictive use of episiotomy. Observational cross-sectional study. Three hundred five midwives completed an anonymous questionnaire developed by the authors and distributed across various midwifery scientific societies. The main outcomes measured were the frequencies of adopting specific practices related to perineal injury prevention and repair, episiotomy technique and restrictive episiotomy use (<10%). Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated. Intrapartum perineal massage was not normally used by 253 (83%) of midwives, and 186 (61%) applied compresses soaked in warm water to the perineum. Regarding episiotomy, there was a great deal of variability, noting that 129 (42.3%) adopted a restrictive use of this procedure, 125 (41%) performed it between 10% and 20%, while 51 midwives (16.7%) performed it in more than 20% of cases. In addition, 165 (54.1%) midwives followed an incision angle of 60º. Concerning tears, 155 (50.8%) usually sutured first-degree tears and 273 (89.5%) always sutured second-degree tears. Midwives attending home births (aOR = 6.5; 95% CI: 2.69-15.69), working at a teaching hospital (aOR = 3.69; 95% CI: 1.39-9.84), and the ones who recently completed their professional training (aOR = 3.58; 95% CI: 1.46-8.79) were significantly more likely to adopt a restrictive use of episiotomy. There is a significant variability in Spanish midwives' practices for preventing and repairing perineal tears. Moreover, the restrictive use of episiotomy is associated with midwives attending home births, working in teaching hospitals and having recent professional training. No patient or public contribution.

Perineal hernia repair following tailgut cyst excision: A case report and literature review of optimal management strategies

Perineal hernias, categorised as primary or secondary, pose a clinical challenge necessitating surgical intervention. Herein we present the surgical management of a postoperative perineal hernia of the retrorectal space. A 42-year-old female patient presented to the clinic with symptoms such as perineal discomfort, bulging, and constipation after previous surgical tailgut cyst excision. Diagnosis involved MRI, confirming rectal herniation into the retrorectal space. The surgical approach featured a perineal intervention using a unilateral inferior gluteal flap to reinforce the posterior rectal space, avoiding mesh complications. The patient experienced a successful recovery, highlighting the importance of tailored interventions based on symptoms and complications. Secondary perineal hernias, often postoperative, present diverse challenges influenced by multiple factors such as pelvic surgeries. Surgical repair options include perineal and abdominal approaches, mesh usage, and flap methods, each with variable outcomes. This case study contributes to the evolving understanding of perineal hernias, emphasising the need for multidisciplinary approaches and ongoing research to enhance management strategies in this complex clinical scenario.

Comparison of Efficacy of Lignocaine Jelly versus Lignocaine Injection during Perineum Repair in Normal Vaginal Delivery

Background: Normal vaginal delivery is frequently associated with perineal trauma that can be iatrogenic (episiotomy) or spontaneous. Episiotomy is the most common surgical procedure in obstetrics being performed in approximately 20% of deliveries&#x0D; Objective: To compare the efficacy of lignocaine Jelly versus lignocaine injection during perineum repair after episiotomy in normal vaginal delivery. &#x0D; Methods: Study was done at Department of Obstetrics &amp; Gynecology, Shalamar Hospital, Lahore during September 2020 - Feb 2021. For this randomized control trial, a total of 160 women fulfilling selection criteria were recruited for study from labour room. Informed consent was obtained from each case. Women were then segregated in group A&amp; B and treatment was randomly allotted using lottery method, while in group A 2% lignocaine Jelly was applied on their perineum during active phase of labour at 8-9 cm cervical dilatation, before estimated time of one hour pre delivery. Women in group B were administered 10 ml of 1% lignocaine injection locally at the proposed site of episiotomy just before crowning. Then females were observed for pain and discomfort or adverse reactions during delivery, perineal repair and in immediate post partum period. After 2 hours of delivery, females were asked for perineal pain using visual analogue scale (VAS) then females were followed up in post-delivery wards for 12 hours. After 12 hours, they were discharged and asked for satisfaction of procedure.&#x0D; Results: The average ages of the cases among Group-A i.e. Lignocaine Jelly group and Lignocaine injection group (group-B) was 26.20 ± 3.32 years and 26.46 ±3.47 years respectively. The mean gestational age in Lignocaine Jelly group was 38.65 ± 0.90 weeks and in Lignocaine injection group was 38.67 ± 0.87 weeks. The mean BMI in Lignocaine Jelly and injection group was 26.70 ± 1.39 and 26.46 ± 2.20 respectively. Average pain score observed in Lignocaine Jelly was 3.58±1.06, whereas in Lignocaine injection group was 4.39 ± 1.26. There was statistically significant difference in average pain scores as the mean pain score in the Lignocaine Jelly group was lower compared with Lignocaine injection group ( p-value ≤ 0.001). In Lignocaine Jelly group 77(96.2%) females were satisfied while in Lignocaine injection group 68(85%) cases were satisfied, higher satisfaction rate was seen in lignocaine Jelly group, p-value (0.015) &#x0D; Conclusion: Women to whom lignocaine Jelly was applied before episiotomy had less mean VAS Pain Score and higher satisfaction rate during perineal repair than women who were given lignocaine injection for perineal repair. So lignocaine Jelly can be used as a good alternative of local infiltration of lignocaine injection, in term of less pain, less adverse effects and more patient satisfaction during perineal repair of birth process.&#x0D;

Repercussions of perineal repair using surgical glue or suture thread on postpartum outcomes: A controlled randomized clinical trial in São Paulo, Brazil.

The type of perineal repair can have significant long-term effects on various functions in a woman's postpartum life. The aim was to compare urinary incontinence (UI), women's satisfaction, pelvic floor muscle strength (PFMS), and sexual function according to the type of perineal repair (surgical glue or suture thread) during the first eight months after normal childbirth. A controlled randomized clinical trial of 133 primiparous women undergoing perineal repair during birth with surgical glue or sutures, evaluated during labor and monitored up to 8 months postpartum, from March 2017 to September 2018, in the city in São Paulo, Bazil. Descriptive and inferential analyses were carried out. A total of 133 women were included in the study, 111 (83.5%) were assessed between 10 to 20 days postpartum, 121 (91.0%) between 50 to 70 days, and 54 (40.6%) between 6 to 8 months. There were no significant differences for UI concerning the type of repair; however, there was a significant difference concerning the postpartum period (p=0.031), with a higher prevalence at two months. Most women reported satisfaction, with the highest levels reported two months after birth (p=0.019). For PFMS, the mean of the glue and suture groups were 32.4 cmH2O and 27.4 cmH2O, but not significant. Women in the glue group showed higher mean values in all sexual function domains but without significance. Surgical glue showed good aesthetic and functional results in the perineum at eight months postpartum.

862 Virtual reality for pain reduction during episiotomy and perineal tear repair

862 Virtual reality for pain reduction during episiotomy and perineal tear repair

Three-Dimensional Transperineal Ultrasound Guiding Early Secondary Repair of Obstetric Anal Sphincter Injury in an Incontinent Patient without Suture Dehiscence.

We present the case of a 36-year-old primigravida who gave birth to a 3200 g baby by vacuum-assisted (Kiwi OmniCup™) operative vaginal delivery with mediolateral episiotomy. A "y"-shaped perineal tear with a grade IIIC obstetric anal sphincter injury (OASI) was diagnosed and repaired. Two days after delivery, in the absence of suture dehiscence, she started experiencing complete anal incontinence. A decision was made in association with a proctologic surgeon for an early secondary repair. Before surgery, a Three-dimensional transperineal ultrasound (TPUS) was performed. The exam revealed a major defect of the external anal sphincter at the 11 o'clock position. This allowed for the reopening of only a circumscribed area of the perineal suture and repair of the sphincters using the end-to-end technique. The symptoms regressed completely, and follow-up TPUS demonstrated the gradual wound healing process. Anal incontinence, secondary to obstetric anal sphincter injury (OASI), has a severe negative impact on women's quality of life. TPUS is an effective method to detect sphincter defects and monitor the healing process. This report investigates the feasibility of identifying the sphincter tear in an incontinent puerperal patient without suture dehiscence in order to target early secondary repair while minimizing its extent. TPUS has proven a safe and effective tool to guide early secondary repair of symptomatic OASI complications while minimizing the invasiveness of the procedure. Multidisciplinary management is crucial to ensure the adequate standard of care.

Cold compared with room temperature compress on the repaired primiparous perineum following injury at normal vaginal delivery: a randomized controlled trial

The perineum is typically injured at the first vaginal birth. The application of a cold compress to the perineal repair site can reduce pain; however, the effect usually dissipates after a couple of hours. Repeated applications may be needed for sustained analgesia. However, the medium-term effect of repeated applications of cold compress on the perineal repair site on the recovery of sexual function and perineal healing is not known. This study aimed to evaluate repeated applications of cold vs room temperature (placebo control) compress to the repaired primiparous perineum on pain upon movement. A randomized controlled trial was conducted in a university hospital in Malaysia from May 2022 to February 2023. A total of 224 women with a repaired episiotomy or spontaneous second-degree tear sustained at normal delivery were randomized as follows: 113 to frozen gel pack and 111 to room temperature gel pack, as wound compress. The compress was applied to the perineal repair site at 3 timepoints: immediately after repair, and at 4 and 8 hours after delivery, for 20 minutes at each application. The primary outcomes were pain during movement at 12 and 24 hours after delivery, scored using the 0 to 10 numerical rating scale. The secondary outcomes include duration of hospital stay; analgesic consumption; recovery and functional metrics of reestablishing flatus, mobilization, and urination, breastfeeding; maternal satisfaction with the allocated compress; and after hospital discharge for up to 6 weeks after birth through telephone interview, analgesic consumption, perineal pain, resumption of vaginal sex, and women's perception of perineal wound healing. The median (interquartile range) of pain at movement scores were 4 (4-5) vs 5 (4-5) (P=.018) at 12 hours and 2 (1-3) vs 2 (2-3) (P=.173) at 24 hours after birth for cold vs room temperature compress, respectively. Maternal satisfaction scores were 8 (7-9) vs 7 (6-8) (P=.119), oral analgesic for perineal pain while at the postnatal ward was taken by 94 of 113 (83.2%) vs 85 of 109 (78.0%) (relative risk, 1.07; 95% confidence interval, 0.94-1.21), and time to the first satisfactory breastfeeding episode was 11.6 (7.9-15.5) vs 13.0 (8.0-20.7) hours (P=.303) for cold vs room temperature compress, respectively. At 2 weeks telephone follow-up, analgesic intake and perineal pain were not different. At 6 weeks, analgesic intake, perineal pain, resumption of vaginal sex, exclusive breastfeeding, and maternal perception of perineal healing were not different. Intermittent cold compress in the first 8 hours to the repaired perineum reduces pain at 12 hours but the effect attenuates by 24 hours. Maternal satisfaction with their allocated compress was not different. There was no suggestion of harm or benefit on the other secondary outcomes.

A Huge Vaginal Prolapse of Uterine Leiomyoma Complicated with Cervical Inversion: A Case Report

Introduction: Uterine fibroids are non-malignant neoplasms originating from the smooth muscle cells of the uterus, and they represent the most prevalent tumor seen within the female reproductive system. The primary established approach to manage this condition is surgical interventions, specifically myomectomy, hysterectomy, or hysteroscopic removal of small subserous nodules. Occasionally, submucous fibroids may protrude through the cervical os, thereby enabling the feasibility of performing a vaginal hysterectomy. Case Presentation: The clinical presentation of a 44-year-old multiparous woman who arrived with symptoms of vaginal bleeding and a sizable mass protruding through the vaginal opening. The patient underwent an emergency vaginal extraction to remove the mass measuring 24 cm in the emergency room and a scheduled for elective surgery. During the procedure, uterine inversion was found with a muscle bundle around the corpus uteri and a fourth-grade perineal tear. This patient was also planned for a total abdominal hysterectomy and bilateral-salphyngo-oophorectomy procedure, along with Haultain's procedure and perineal repair. The patient exhibited favorable surgical outcomes. Conclusion: Hysterectomy is the preferred therapy for prolapsed pedunculated submucous myoma. It has been seen that even exceptionally big nascent myomas can be effectively removed using vaginal means.

Objective structured assessment of medical students’ technical skills in second-degree perineal laceration repair with sponge model-based training

PurposeIn this cohort study, we used a sponge simulator to train students in second-degree perineal laceration repair. We examined whether the training course improved the students’ skills, as measured with an objective structured assessment of technical skills (OSATS) and by a senior physician. We also examined the correlation between these ratings to assess the validity of OSATS application in this context.MethodsBetween April and July 2022, 40 medical students took part in gynecological/obstetrics training that included a lecture about perineal trauma and the viewing of a video that demonstrated second-degree perineal laceration repair using a sponge model. They then underwent initial evaluation by a senior physician and OSATS application, yielding two independent scores. After training with the sponge model, a second evaluation was performed. The OSATS assessed practical skills (8 items) and suture results (2 items). The senior physician assigned ratings on a five-point ordinal scale ranging from 1 (excellent) to 5 (poor).ResultsTraining with the sponge simulator significantly increased students’ OSATS (practical skills, p < 0.001; suture results, p < 0.05) and senior physician (p < 0.001) ratings. The OSATS and senior physician ratings correlated strongly (Spearman’s r: first assessment, – 0.72; second assessment, – 0.74; p < 0.01).ConclusionThe sponge-based training improves students’ skills for the repair of a second-degree perineal laceration. The OSATS for the sponge model might be a valid option to examine medical students in an obstetrical course.

Clinical and Aesthetic Review of Episiotomy Wound Closure Methods.

An episiotomy is a surgical incision in the perineum to facilitate the baby's head during delivery. Physicians or midwives may use this procedure if he/she finds out the tissue around the vaginal opening begins tearing or does not seem to be stretching enough to allow the baby to be delivered. With an increasing trend for hospital births and for physicians to get involved in the normal uncomplicated birth process, there was rise in the number of episiotomies. After the baby is delivered through the extended vaginal opening, the area is applied with local anesthetic agent and incision is repaired with sutures. Our study reviewed the development in the past twenty years regarding episiotomy wound closure methods, and discovered that continuous sutures for episiotomy or perineal repair have clinical advantages in term of faster and better wound healing, more favorable scarring, shorter post-procedural pain, more rapid resumption of sexual activity, lower incidence of urinary incontinence, compared to interrupted sutures. They were also beneficial in term of less consumption of suture materials. In determining suture materials, clinicians should strongly consider the tear severity, tissue characteristics, as well as the desired aesthetic outcome.

Efficacy of lumbosacral and sacrococcygeal epidural ropivacaine in dogs undergoing surgery for perineal hernia.

Epidural anesthesia is commonly administered as part of balanced anesthesia for perioperative analgesia. The main goal of this randomized clinical trial was to compare the efficacy of two epidural approaches in dogs undergoing surgery for a perineal hernia. A secondary aim was to compare motor blockade. Intact ASA 1 and 2 male dogs, weighing ≤25 kg with no previous surgery for perineal hernia were enrolled. After premedication with IM acepromazine 0.02 mg/kg and butorphanol 0.3 mg/kg, general anesthesia was induced with propofol and maintained with sevoflurane in oxygen. Dogs were randomly allocated to receive either a lumbosacral (LS, n = 30) or a sacrococcygeal (SC, n = 26) epidural injection with ropivacaine 1% (0.2 mL/kg) under computed tomography guidance. Successful analgesia was defined as no need of intraoperative rescue analgesia (fentanyl 3 μg/kg IV). Clinical failure was defined as the need of more than two boluses of fentanyl/h each dog received meloxicam 0.2 mg/kg IV at the end of the surgery. The Glasgow Composite Pain Scale short form (GCPS-SF), tactile sensitivity, pressure pain thresholds and motor blockade were assessed at 4, 6, 8, and 24 h after the epidural injection. Methadone (0.2 mg/kg, IV) was administered if the GCPS-SF was ≥6/24 points. Differences between groups were analyzed with the Mann-Whitney U test, Student's t-test or Fisher's Exact test, as appropriate. Success rate was assessed for non-inferiority between groups. The non-inferiority margin was set at -10%. Epidural analgesia was successful in 24 dogs in group LS and 17 dogs in group SC (p = 0.243), resulting in success rates of 80 and 65% in LS and SC groups, respectively. The non-inferiority of group SC versus group LS was confirmed. Clinical failure was recorded in two dogs in group LS and one dog in group SC. No significant differences between groups were detected in the GCPS-SF score, tactile sensitivity, pressure pain thresholds, need of post-operative methadone, or motor blockade. Both epidural techniques are valuable analgesic options for perineal hernia repair in dogs.

CONSERVATIVE MANAGEMENT PELVIC FRACTURE URETHRAL INJURY (PFUI) IN A GIRL: A CASE REPORT

ABSTRACT&#x0D; Objective: This case report aims to describe a different approach of PFUI by conservative management that resulted in good outcome. Case(s) Presentation: A 7-year-old girl patient was brought to the emergency department after falling from public transportation diagnosed with suspicious urethral rupture, perineal rupture grade III, vertical-shear type pelvic-ring injury, laceration wound on the right lower leg, abrasion on the medial side left lower leg and urinary retention. The patient underwent percutaneous cystostomy, pelvic bandage, a perineal debridement and repair, a cystography, percutaneous vesicolithotripsy, cystostomy and synechiae incision. One year after the first admission it was planned for urethroplasty due to completely obliterated from antegrade and retrograde panendoscopy. Discussion: 8 months later urethroplasty was aborted because of an open bladder neck, a fistula at the anterior connected to the distal of the bladder neck with size of 3 mm. The patient was performed a silicon cystostomy catheter insertion for 6 weeks. At the time of evaluation, the fistula was closed, it was proven by Qmax uroflowmetry was 18ml/s with average flow: 9.8 ml/s, voiding volume: 90ml, flow time: 9s, voiding time: 9s, hesistance:1.5, and PVR:5.35 cc. Conclusion: In this case, it showed that conservative management could improve PFUI with satisfactory result, proved by good result of uroflowmetry. However, periodic evaluations must be carried out to follow the progress of the disease and the possibility of future complications including sexual function.&#x0D; Keywords: PFUI, girl, urethral rupture

Lower partial pubicectomy for postoperative complicated posterior urethral stricture

ObjectiveTo report the experience of partial inferior pubicectomy in the treatment of complex posterior urethral stricture after trauma.MethodsA total of 46 patients with post-traumatic posterior urethral stricture admitted to the Department of Urology of our Hospital from January 2013 to September 2021 were selected as the research objects and underwent urethroplasty (including nine patients who had failed previous perineal repair surgery and adopted partial inferior pubicectomy approach). Retrograde urethrograph (RUG) and urine flow measurement were performed at 1, 3, 12 and 18 months after operation, and follow-up was performed when necessary. The clinical data during treatment were statistically analyzed.ResultsAll 46 patients underwent urethroplasty successfully, of which nine were treated with partial pubicectomy, accounting for 19.57% of the total. The causes of the disease were motor vehicle accident in 4 cases, falling collision injury in 2 cases, and rolling injury of military exercise tank in 3 cases. Among the 9 patients, 2 were children (22.22%), aged 8 and 12 years, and 7 were adults (77.78%), aged 19–44 (28.42 ± 1.56) years. Among the 9 patients, 6 had erectile dysfunction, accounting for 66.67%. The length of posterior urinary tract stenosis was (5.12 ± 0.57) cm. The operation time was (290.34 ± 12.35) min from anesthesia induction to skin closure. Five patients received 2 U blood transfusion during operation and three patients received 3 U blood transfusion after operation. The average hospital stay was 12–16 (14.24 ± 1.25) days, and the follow-up was 12–24 (18.24 ± 1.35) months. After surgery, one patient developed HIP abscess, which was successfully treated conservatively. One patient had dysuria 1 month after operation and was successfully treated by transurethral dilatation. One case had postoperative infection and recovered after intravenous administration of potent antibiotics. Cystourethrography was performed 3 months after operation, and there was no difference between patients with wide, long or short anastomotic stretch defects. All patients met the criteria for surgical success.ConclusionPartial inferior pubicectomy is a good surgical procedure for the repair of complicated posterior urethral stricture after operation. It is safe and reliable, can better display the prostatic apex and surgical field, shorten the length of reconstructed urethra, and has good postoperative effect. It has no direct or long-term effect on the stability of pelvis or bladder. However, further studies in a larger cohort of patients with complex posterior urethral strictures after repair are needed to demonstrate the specific indications for partial pubicectomy.

Comparison of long-term clinical outcomes between transvaginal mesh and pelvic floor reconstruction with native tissue repair in the treatment of advanced pelvic organ prolapse

Objective: To study the long-term clinical effect of transvaginal mesh (TVM) and pelvic floor reconstruction with native tissue repair (NTR) in the treatment of advanced pelvic organ prolapse (POP). Methods: Totally 207 patients with advanced POP who were treated in Hunan Provincial Maternal and Child Health Care Hospital from Jan. 2016 to Sep. 2019 were enrolled. The patient's pelvic organ prolapse quantification were all at degree Ⅲ or above, and they all complained for different degree of symptoms. They were divided into two groups according to the different surgical methods, TVM group and NTR group. In TVM group, the mesh was implanted through the vagina for pelvic floor reconstruction, while in NTR group, the traditional transvaginal hysterectomy combined with uterosacral ligament suspension and anterior and posterior wall repair, as well as perineal body repair were performed. The median follow-up time was 60 months, during the follow up time, 164 cases (79.2%, 164/207) had completed follow-up, including 76 cases in TVM group and 88 cases in NTR group. The perioperative data and complication rates of the two groups were compared, and the subjective and objective outcomes of the two groups at 1, 3 and 5 years were observed, respectively. The objective efficacy was evaluated by three composite criteria, namely: (1) the distance from the farthest end of the prolapse of the anterior and posterior wall of the vagina to the hymen is ≤0 cm, and the descending distance of the top is ≤1/2 of the total length of the vagina; (2) determine the disappearance of relevant POP symptoms according to "Do you often see or feel vaginal mass prolapse？"; (3) no further operation or pessary treatment was performed due to prolapse. If the above three criteria were met at the same time, the operation is successful; otherwise, it was recurrence. The subjective efficacy was evaluated by the pelvic floor distress inventory-short form 20 (PFDI-20) and pelvic floor impact questionnaire-short form 7 (PFIQ-7). Results: The median follow-up time of the two groups was 60 months (range: 41-82 months). Five years after the operation, the subjective and objective cure rates of TVM group were 89.5% (68/76) and 94.7% (72/76), respectively. The subjective and objective cure rates in NTR group were 80.7% (71/88) and 85.2% (75/88), respectively. There were significant differences in the subjective and objective cure rates between the two groups (χ2=9.869, P=0.002; χ2=3.969, P=0.046). The recurrence rate of TVM group was 5.3% (4/76), and that of NTR group was 14.8% (13/88). There was a significant difference between the two groups (P=0.046). The postoperative PFDI-20 and PFIQ-7 scores of the two groups were significantly lower than those before surgery, and there were significant differences of the two groups before and after surgery (all P<0.05). Postoperative mesh exposure in TVM group was 1.3% (1/76). Conclusions: The long-term outcomes between the two groups show that the subjective and objective outcomes of pelvic floor reconstruction in TVM group are significantly higher than those in NTR group, and the recurrence rate is significantly lower than that in NTR group. TVM has certain advantages in the treatment of advanced POP.

Short- and mid-term outcomes of abdominoperineal resection with perineal mesh insertion: a single-centre experience.

Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging, particularly in extralevator abdominoperineal resection (ELAPR) due to gapped tissue planes. Different approaches have been attempted to improve perineal wound repair. The aim of this study is to report our 6-year experience in perineal wound closure utilising biological mesh. We conducted a retrospective study using data from our prospectively maintained database, including patients who underwent APR with perineal mesh closure between 2016 and 2021. 49 patients underwent APR with perineal mesh reconstruction for low rectal cancer during the 6-year period. Of these, 63% were males, with a mean age of 68 (± 11), and a mean BMI of 27.9 (± 13.7). 49% (24) of patients received neoadjuvant therapy. 88% (43) of patients underwent standard "S-APR" and only 12% (6) underwent ELAPR. Majority of procedures were laparoscopic (87.8%) with conversion rate of 6.9%. Mean length of stay was 11.7 (± 11.6). The perineal wound infection rate was 30% and only two patient required mesh removal due to entero-cutaneous perineal fistula and pelvic abscess. Perineal hernia was found in only two patients (4.1%). CRM was negative in 81.6% of the patients. Mean follow-up period was 29.2 (± 16.5) months, and disease recurrence occurred in 9 (18.3%) patients with average number of months for recurrence of21 (± 7). Overall survival during the follow-up period was 91%. Our series shows a favourable short- and medium-term outcome with routine insertion of mesh for perineal wound closure.

Perineal Hernia in a Previously Operated Patient of Prolapse: A Case Report

Perineal hernia can occur in patients after abdominal or pelvic surgeries, especially in those who are immunosuppressed, have a history of laparoscopy, or are of the female sex. Patients with a perineal hernia may be asymptomatic or complain of urinary or bowel disturbance or pain. Our patient was a 63-year-old symptomatic female with a history of vaginal hysterectomy and laparoscopic sacrospinous fixation. She presented with heaviness in the lower abdomen and increased stooling frequency. She was found to have a perineal hernia up to the right ischioanal fossa, with grade four vaginal vault prolapse. Laparoscopic sacrocolpopexy with levator ani plication with perineal hernia repair was performed. We used a T-shaped mesh composed of monofilament polypropylene with a combination of synthetic sutures to plicate the levator ani bilaterally and repair the vault prolapse. The postoperative course has been favorable. As of 12 months postoperative, there are no fresh complaints. The use of mesh (e.g., polypropylene) is important for levator ani repair for reinforcement. Laparoscopic repair is generally preferred, as it provides better access with a lesser risk of complication. Almost all cases of perineal hernia in literature have been after colorectal surgery and with no specific protocol for management. A standardized surgical approach with a scope for individualization would be helpful.

Is a pedicular flap coupled to the double turnover flaps urethroplasty suitable for urethral–perineal reconstruction? Considerations about a relapsing urethral–cutaneous fistula condition

Background: This study highlights the effectiveness, in one surgical stage, of two combined local techniques for perineal fistula repair in a patient with spinal cord injury: the " Turn over flaps urethroplasty" and the "Pedicular fasciocutaneous flap" from the inferior gluteal fold. Unlike the traditional Perforator flap, we harvested a Pedicular flap; by definition, this is a flap with a narrow diffuse microvascular supply aimed in our case at shielding the neourethra and substituting the remaining scarred perineum. Method: The urethroplasty technique adopted, the 'Double turn over flaps urethroplasty', has been based on sculpting two opposing local cutaneous flaps circumscribing the fistulous cutaneous openings. Eventually, the neourethra continuity has been re-established by turning over both flaps and making them meet medially. The dimension and thickness of the "Pedicular fasciocutaneous flap", have been considered to prevent any damage to the urethroplasty and at the same time to replace all the debrided scarred perineal tissue. Results: The follow-up confirmed a well-consolidated supple perineal area and a competent neourethra. Conclusions: The "Pedicular flap" is by definition a random vascular flap nourished through a narrow pedicle, not based on a single perforator but only on a diffuse, spread micro-perforators. When associated with the double "Turn over flaps urethroplasty", it represents a possible alternative to achieve satisfactory results for those physical and psychological challenges encountered in the treatment of recurrent urethral fistula of the perineum in a patient with spinal cord injury.

Perineal repair performed by midwives in Australia: A cross-sectional survey study of education and practice

ProblemPerineal repair is generally not a widely practiced skill amongst Australian midwives, the reasons for this are uncertain and may result in technique variations. BackgroundMany birthing women experience perineal tears that require suturing. As midwives attend the majority of vaginal births, they would be ideally placed to undertake perineal repair. AimTo describe the current level of midwifery perineal repair skill acquisition, knowledge, techniques and utilization by Australian midwives. MethodsAn online survey was distributed to Australian College of Midwives members and shared via social media. Data on demographics, suturing techniques, reasons why midwives did or did not suture and barriers to skill acquisition were collected. Descriptive statistics were calculated for all variables including percentages, mean, standard deviation, median and range as appropriate. Findings375 completed surveys were received between April and May 2023. 197 midwives indicated current suturing practice and 178 did not suture. Contributing to continuity of care was the most common motivating factor. The use of a continuous suturing technique for all layers of a perineal injury was reported by the majority of suturing midwives. There was greater variation in the management of labial tears. Low numbers of skilled midwives to support attaining competency and high workloads were the main barriers to attaining suturing skills. DiscussionAustralian midwives view perineal suturing as a valid midwifery skill that can contribute to continuity of care. Largely organisational barriers exist to skill development and greater utilisation. ConclusionPerineal repair should be prioritised as a fundamental midwifery skill.